HELMET DAY! LESSONS LEARNED

ON VIETNAM’S ROAD TO HEALTHY BEHAVIOR

The Social Science Research Council (SSRC) leads innovation, builds interdisciplinary and international networks, and focuses research on important public issues. We bring necessary knowledge to public action.

SSRC Strategic Learning & Evaluation Research Team:

Mary Byrne McDonnell Principal Investigator

Van Bich Thi Tran Project Coordinator

Nina R. McCoy Vietnam Representative

May 2010This work may be freely republished, redistributed, and used by others, provided that (i) it is for non-commercial purposes, (ii) the content of the work is not altered, and (iii) SSRC and the author(s) are properly credited as the source of the published work.

Cover photo: Jackie Williams Kaye, Strategic Learning and Evaluation Executive, The Atlantic Philanthropies

Design: Kate NorthernEditor: Alyson Metzger

The strategic learning and evaluation research underpinning this report and the work on helmet usage in Vietnam were made possible through generous grants from The Atlantic Philanthropies and others.

The Atlantic Philanthropies are dedicated to bringing about lasting changes in the lives of disadvantaged and vulnerable people. Atlantic focuses on four critical social problems: Ageing, Children & Youth, Population Health, and Reconciliation & Human Rights. Programmes funded by Atlantic operate in Australia, Bermuda, Northern Ireland, the Republic of Ireland, South Africa, the United States and Viet Nam. To learn more, please visit: www.atlanticphilanthropies.org.

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HELMET DAY IN VIETNAM: AN AMAZING, MAGICAL SCENE

1990–1996: STIRRINGS OF CHANGE

1997–2001: PREVENTION & HELMET USE COMING INTO FOCUS

2002–2007: MAKING & WEARING HELMETS

WHAT WAS DIFFERENT THIS TIME?

SUSTAINING & FINE-TUNING SUCCESS

LESSONS LEARNED: POTENTIAL APPLICATIONS TO OTHER PUBLIC HEALTH BEHAVIOR CHANGE PROGRAMS

APPENDIX: THE ACTORS IN VIETNAM’S HELMET STORY

On the morning of December 15, other dignitaries and I planted ourselves at the Daewoo Hotel intersection [in Ha Noi] with TV crews and other journalists. We wanted to find four or five people who were not wearing helmets, who could be filmed getting fined by police. There was no job for the police to do and nothing for TV to film. . . . There was 100% compliance.

Bui Huynh Long Secretary, National Traffic Safety Committee

AN AMAZING, MAGICAL SCENE

HELMET DAY IN VIETNAM

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On December 14th, no one in all of Vietnam would have predicted this enormous success. In Ha Noi, there was no stampede to buy helmets. Certainly, almost no one had them on their heads. As the work week drew to a close, it was mostly business as usual and traffic chaos as on any other Friday evening. There was a sense of anticipation among people working with helmet use projects, but no one was betting on anything. Nothing on the streets signaled that the next morning would display such a radical change.

What made the achievement of Helmet Day possible? The journey was not simple or easy. Multiple players contributed in a variety of ways over many stages across several decades. Each particular time period enabled – or set up obstacles to – each step taken. Forward action depended on two enabling factors: (1) the level of political will within the Vietnamese Government to come to grips with what needed to be done and to both create needed regulation

and provide for its implementation, and (2) the coalescing of funding, passion, vision, and leadership among international and Vietnamese actors to both promote and support necessary action. While these elements were present in different ways at different times, only when both factors came together in full measure did universal, compulsory helmet use come to pass.

Our Helmet Day story provides a lens on the process of creating achievable policy and behavioral change and offers a set of lessons learned that in whole or in part may be applicable to other public health issues and national settings where changing individual behavior and culturally accepted norms of behavior is a goal. We share our experience in the hope that it will encourage and guide others who set out to prevent injury and illness in Vietnam and elsewhere.

There was 100%

compliance.

Motorcycle helmets became mandatory in Vietnam on December 15, 2007. When residents and visitors stepped outside that Saturday, they faced a beautiful, colorful sea of helmets on the heads of the adults and children riding by.

HELMET DAY IN VIETNAM HA NOI VIETNAM

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1990–1996: STIRRINGS OF

CHANGE

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When the American War ended in 1975, the Vietnamese began the difficult task of reuniting their nation. The Doi Moi reform process launched in 1986 has led to rapid urbanization and socio-economic development. By the mid 1990s, Vietnam’s economy was booming, with most people switching with staggering speed from bicycle to motorcycle use. In urban areas, automobile numbers also burgeoned in response to economic growth. Vietnam seemed to be making a change to motorized vehicles more rapidly than any other country in the world.

With motorization came traffic accidents, and with traffic accidents came preventable motorcycle injuries and deaths. The need to change behavior – to somehow get Vietnamese of all ages to wear motorcycle helmets – was clear.

1 Center for Injury Prevention and Policy Research, “Study Report on Traffic Injury Situation in Provinces of Yen Bai, Da Nang and Binh Duong,” draft, February 2008, Ha Noi School of Public Health.2 Asian Development Bank and Association of Southeast Asian Nations, Regional Road Safety Program Accident Costing Report: The Cost of Road Traffic Accidents in Vietnam (Manila: ADB/ASEAN, 2003).

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Traffic Accidents, Fatalities, and Injuries and Number of Motorcycles: 1990–2007

Acciden

ts, Fatalities, Injuries (Tho

usan

ds)

Motorized

 Veh

icles (M

illions)

Traffic Accidents Traffic Fatalities Traffic Injuries

Number of Automobiles Number of Motorcycles

35

30

25

20

15

10

5

0

25

20

15

10

5

0

1990

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Source: Authors based on data from the National Traffic Safety Committee and the Ministry of Transport.

The number of traffic accidents in Vietnam increased significantly each year from 1990 to 2002, as presented in the chart below. By the end of 2007, even though the number of traffic accidents had declined, the mortality rates and seriousness of injuries remained very high, with traffic accidents resulting in an average of 38 deaths a day and close to 14,000 for the year – 2,000 of them children. 30,000 cases of severe brain damage and head injury – 6,000 of them in children – were recorded. Traffic accidents were the leading cause of death that year for all people aged 18–45 years.1

On the economic side, the Asian Development Bank showed, as early as 2003, that road accidents cost Vietnam at least $900 million each year, which was equal to 2.7% of Vietnam’s GDP. 2

Approximate Number of Motorcycles in Use Countrywide

Year

Motorcycles

1990

500,000

1997

3,000,000

1999

6,000,000

2004

14,000,000

2007

21,000,000

THE ENABLING ENVIRONMENT UNDERSTANDING CONNECTIONS

In the initial wave of motorization, there was very little movement toward helmet imperatives. The Government saw the emerging chaos on the roads as a problem but had not recognized the significance of motorcycle accidents or injuries and did not draw a connection between accidents, serious head injuries, and helmets. The magnitude of the problem had yet to be realized internally, and external pressure had not yet come to bear.

POLITICAL WILL & GOVERNMENT ACTION A LOCAL FALSE START & A NATIONAL CHAMPION This early period did see a brief local attempt at requiring helmet use. In 1993, Ho Chi Minh City – already facing a dramatic rise in motorcycle accident injuries and deaths that the rest of Vietnam would experience later – mandated helmet use within the city. A year later, City authorities halted implementation and repealed the law. One explana-tion given for this about-face was that the City exceeded its authority to regulate when there was no national helmet mandate. It was also reported that there were not enough helmets available amid public complaints about helmet cost and necessity. Bui Huynh Long, working in the legal department of the Ministry of Transport on the first national set of rules for traffic order and safety, recognized the legal obstacle and included a helmet wearing clause but was un-able to promote it as a solution. However, Mr. Long emerged as a champion of the helmet cause and would become a strong partner for international players as their involvement and influence grew around the helmet issue.

FUNDING, PASSION, VISION, & LEADERSHIP A GRADUAL REALIZATION The first stirrings of international interest in helmet use came in 1991 with the establishment of the WHO/FIA Foundation Helmet Initiative, created to promote the use of motorcycle and bicycle helmets worldwide. Awareness was spreading that needlessly large numbers of people were being killed or permanently disabled as a result of a head injury received from a motorcycle fall or during a crash, head injuries that could have been prevented or been less severe through the use of a simple and inexpensive helmet.

The only significant funding available for injury prevention work in Vietnam at this time was bilateral aid through the Swedish International Development Authority (SIDA – now the Swedish International Development Cooperation Agency). In 1994, Vietnam and Sweden entered into a five-year health cooperation agreement to develop a legal framework for the health sector, in general, and to address accidents and injuries as urgent health problems. A Safe Community model was piloted by the Ministry of Health, with the guidance of the model’s originator, Swedish professor Leif Svanström. Promoted globally beginning in 1989, the Safe Community model was seen as an effective grassroots solution for reducing injuries and accidents in everyday life – at home, in school, and at work. Although a few pilot projects were carried out, universal, mandatory helmet use had not yet been identified as an urgently needed solution.

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1997 was a year destined to change the direction of injury prevention work in Vietnam. Two actors appeared on the scene who would stress that it was time to stop the carnage on the roads and highways and time to put helmets on everyone’s heads.

The 1st U.S. Ambassador Arrives

When the first U.S. ambassador, Pete Peterson, arrived in Vietnam in 1997, he began to raise the profile of road traffic safety and helmet use. Having lost a son in a traffic accident, he was a man with a personal passion for injury prevention work. He also believed that accidents were a great waste of Vietnam’s resources and therefore a drag on development. But most of all, he wanted to save lives. Ambassador Peterson saw injury prevention as a non-controversial area for U.S. participation and wanted to find a way to build capacity inside existing systems. In 1999, he became a founding member of The Safe Viet Nam Initiative and years later created the non-profit organization The Alliance for Safe Children, dedicated to making the prevention of child injuries a reality in the developing world.

The National Traffic Safety Committee Is EstablishedThe Government created the National Traffic Safety Committee (NTSC) in 1997 to advise the Prime Minister on strategic and policy directions for ensuring traffic order and safety, coordinate public information and education outreach efforts, and report on the activities of ministries, sectors, and localities in performing the work of ensuring traffic order and safety. A purely Vietnamese initiative, the NTSC would become a major partner to many international groups that would come to work on the helmet issue.

1997 A TIPPING POINT

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1997–2001: PREVENTION & HELMET USE COMING INTO FOCUS

A national helmet use policy is urgently needed.

Ha Noi School of Public Health Report to UNICEF on the 2001 Vietnam Multi-Center Injury Survey

The formation of the NTSC in 1997 was a major step forward for traffic safety in Vietnam, and helmet-related activity grew in depth and breadth between 1997 and 2001. Despite an overall failure to achieve the desired mass impact, the various small campaigns carried out over this period may have helped ease people into the idea of helmet use.

In 2001, as Vietnam was growing more receptive to a public health approach to reducing accidents and injuries, the Prime Minister issued a decree establishing the Ha Noi School of Public Health (HSPH) as a new agent of change to help develop modern public health. The first sound research on which to base injury-related policy and public education and advocacy was accomplished that same year – the 2001 Vietnam Multi-Center Injury Survey. Funded by UNICEF and carried out by the HSPH in collaboration with the Ministry of Health, this was Vietnam’s first national household survey on injury and, at the time, the largest ever accomplished in Asia. The Government initially balked at accepting the results because they were more serious than expected but later would use evidence from the report, such as the accident rate, to underpin action.

THE ENABLING ENVIRONMENT SUDDEN AWAKENING & SOME MOMENTUM

This period saw a sea change in attitudes toward helmet use. There was a lot of energy, enthusiasm, commitment, and leadership shown by various international groups and individuals and their Vietnamese partners working on injury prevention and helmet-related programming. The snapshot of the period was of U.S. President Bill Clinton handing out the first Helmets for Kids to Vietnamese schoolchildren. This increase in interest and the growing number of players – both inside and outside the Government – began to produce forward momentum. Nonetheless, for every step forward there was often a setback.

POLITICAL WILL & GOVERNMENT ACTION MORE DRIVE BUT DISJOINTED ACTION

Although there began to be a significant increase in political will and government action around the helmet issue, with more political actors joining the movement, legislative efforts became disjointed. The result was a pattern of legislation and implementation attempts that lacked clarity and appropriate sanction, culminating in the National Assembly authorizing the Government to stipulate helmet wearing within the 2001 Law on Road Traffic. While the Ministry of Transport became engaged in the issue, other critical ministries did not join in or were left out. The responsibility for controlling traffic accidents was still seen as the sole purview of the Ministry of Transport and the traffic police, making it hard to forge the needed cooperation among the relevant ministries.

A major breakthrough came at the end of 2001 with the adoption of the National Policy on Accident and Injury Prevention and Control for 2002–2010. A multi-sector National Steering Committee on Injury Prevention and Control formed at the same time, chaired by the Ministry of Health and including the Ministry of Transport.

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By the beginning of 2002, it was clear that both the Vietnamese Government and their international partners were determined to develop mandatory helmet use regulations that could be successfully implemented. Along with the fact that in 2002 Vietnam recorded the most traffic accident deaths and injuries ever, the following events made this year a tipping point:

AIPF’s Protec Helmet Factory OpensWith the opening of a factory to produce appropriate, affordable tropical helmets for both adults and children, AIPF began to develop a high profile for non-profit helmet manufacturing and mandatory helmet use.

A Strong Resolution Passes and the Party Engages

The Government approved Resolution No. 13 to check the rise in and gradually reduce traffic accidents and congestion. A few months later, the Party became actively involved and issued a directive to strengthen leadership countrywide to solve the problem of rising traffic accidents, deaths, and injuries. Results of both interventions included placing the Minister of Transport at the head of the NTSC and the Chairs of the Provincial People’s Committees as leaders of the provincial Traffic Safety Committees. These officials would now be held accountable for the traffic accidents, injuries, and deaths in their localities.

2002 A TIPPING POINT

A New NTSC Secretary Takes the Lead Bui Huynh Long – who had served on the NTSC in different positions since 1997, emerging as a helmet use champion – assumed leadership of the NTSC, giving international groups working on helmet use programs a passionate, committed government partner.

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FUNDING, PASSION, VISION, & LEADERSHIP JOINING FORCES

Alongside the growing domestic political will, a vibrant international community was developing around injury prevention work and in particular helmet use programming. It was an unusual time, rich in people who were highly motivated and completely committed to success. Many more international groups also became involved, pushed and prodded initially by Ambassador Peterson and Mike Linnan, the U.S. Embassy Health Attaché for the Centers for Disease Control and Prevention (CDC). In 1999, Pete Peterson and Mike Linnan, in collaboration with the Ministry of Health and Morten Giersing, the UNICEF Country Representative, started The Safe Viet Nam Initiative, a network of the NTSC, the Ministry of Health, other ministries and agencies, and a range of international organizations, including Asia Injury Prevention Foundation (AIPF), UNICEF, SIDA, and the U.S. and Australian embassies. (See the Appendix for a detailed list of the many critical actors in Vietnam’s helmet story over the years.)

American funding became an important factor, and here too Ambassador Peterson served as a catalyst. After tapping the CDC and USAID for help, he and Mike Linnan also convinced Chuck Feeney, the founder of The Atlantic Philanthropies (Atlantic), to invest in injury prevention work and put him in touch with AIPF and UNICEF Vietnam. Atlantic gave its first injury prevention grants to the U.S. Fund for UNICEF (for UNICEF Vietnam) and AIPF in 2000, deeming AIPF’s project doable largely due to the grounding provided by The Safe Viet Nam Initiative. As a condition of its grant making, Atlantic’s funding was matched by funds from the corporate sector, foundations, and others. Securing these funds took a great deal of patience, searching, and negotiating, but in the end, bought a helmet factory to produce appropriate tropical helmets in Vietnam.

VIETNAM’S 1ST MANDATORY HELMET USE LAWIn this interim period from 1997 to 2001, the basis was clearly established for a successful future helmet use campaign. Necessary conditions were in place for a first attempt at mandating helmet use, but they were not yet sufficient to enable success.

The National Assembly gave the Government legal authority to mandate and sanction helmet use in the 2001 Law on Road Traffic. However, this covered only some roads and imposed only a minor fine. The traffic police force was still too thin to cover even the few selected highways where helmet wearing was compulsory, and police remained more interested in public order on roads than in public health.

There was not enough money for streetlights and “compulsory helmet road” signs, let alone the necessary public education and awareness campaigns. While there was a Government budget for public education at this time, we cannot say how much there was or how it was used to promote helmet use work. From the poor quality of the public education materials we observed, it is probable that the overall budget was modest.

Quality helmets were still too expensive for most. Even though standards for them were in place, AIPF had not yet started production of Protec tropical helmets. The Ministry of Transport’s solution of setting up helmet rental booths where roads connected to national highways was not effective. With a low fine and little possibility of detection, many were willing to risk riding without helmets.

From this first attempt at mandating helmet use, the NTSC learned that a helmet law without adequate fines, incentives for enforcement (including enough police), and adequately funded public education would not be successful. Helmets had to be acceptable, and the public had to clearly understand the need for them – particularly in urban areas where most motorcycles were registered. New approaches needed to be found.

Helmet use partners were also learning that they needed to improve their timing. The Government got ahead of itself in declaring helmet use decisions and campaigns, and AIPF got ahead of itself in launching a Helmets for Kids program before there was a factory to make them. The NTSC reported that it did not have enough money to implement all the projects in its first road safety action plan.

2002–2007: MAKING & WEARING HELMETS

2001’s failed attempt at national helmet wearing led to reassessment and renewed energy. The Government gradually expanded the scope of the law to include more highways and – in 2004 – provincial roads. Complaints abounded from all quarters. Some said the law discriminated against rural people and was intended to keep them out of the cities. On the other hand, urbanites did not want people to think they were from the “countryside” and so did not voluntarily wear helmets. People did not want to be “different” in a social context where conformity is highly valued.

Up to mid 2007, there was no clear, universal, mandatory helmet policy, despite the many resolutions, directives, and other legal devices put into play, and there had been no consolidated outreach to change public perception of helmet use. Both the Vietnamese leadership and international leaders and staff pushed the edges as far as they could go to bring about the successful conclusion we know as Helmet Day.

THE ENABLING ENVIRONMENT AN INTENSIVE PUSH FOR SUCCESS

If the period between 1997 and 2001 had seemed full of new helmet use projects and players, it was nothing like the crowded field that developed over the next five years. The number of people and organizations involved exploded, resulting in many major projects that directly contributed to or had some bearing on the Helmet Day story. All the

relevant ministries were now engaged. The Party strongly signaled the problem as a priority. The media was taking up the cause, and local celebrities even became involved. There continued to be starts and stops on the road to success, but all the actors believed the effort toward compulsory helmet usage was firmly on track.

POLITICAL WILL & GOVERNMENT ACTION WORKABLE LAWS & SERIOUS IMPLEMENTATION

Government efforts before 2002 were unilateral and did not have the support of all relevant bodies. From 2002 on, the Government agreed that helmets would be worn on national highways that posted signs stating that helmets were required, and this became the “law.” Signs were posted, and fines were imposed on some highways. Regulating only national highways and provincial roads covered about 18% of Vietnam’s road system, missing the cities where motorcycle use was highest. Local leadership varied, so action and enforcement were not consistent from one locale to another. Helmet usage was growing, but due to the lack of universality in what was required on which roads and the unevenness of sanctions and their enforcement, it remained the exception, not the rule – especially in the cities.

Shortly after the NTSC – under Mr. Long’s leadership – presented a well-crafted National Helmet Action Plan, Mr. Long and the Minister of Transport leveraged Vietnam’s expression of strong

support for the APEC Road Traffic Safety Resolution to engage the attention and support of the Prime Minister for their helmet plan. In mid 2007, the Government unanimously agreed helmet wearing would be compulsory for all from September 15th on all national highways and then from December 15th on all roads. The national universal helmet policy was issued at the end of June in Government Resolution No. 32, which also included a number of urgent measures to control traffic accidents and congestion. This resolution triggered the chain of events to ensure all related laws and subordinate policies conformed. The sanction law was amended, and fines were beefed up significantly.

The political will that led to the Government’s helmet policy extended to the Party, a largely missing element in earlier periods. Provincial People’s Committee Chairs (the highest ranking party officials in provinces and the equivalent of governors) became the heads of local branches of the NTSC, thus lodging responsibility for traffic safety, injuries, and mortality squarely with those leaders responsible for implementing national policy at the local level. In August 2007, the Party issued a report that affirmed that road safety is a political task – and a mass task – and stated that all must comply with and implement Resolution No. 32. This was the authority the Prime Minister needed to issue a formal directive to all branches, agencies, offices, and political-social organizations at every level to mobilize them to make sure everyone knew about the rules and the fines and would be wearing their helmets on December 15th.

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In early 2007 only 3% of the population wore a helmet when on a motorbike.

Greig Craft President, Asia Injury Prevention Foundation3

3 Greig Craft, “Roadmap for a Successful Helmet Wearing Initiative, 2007–2008,” unpublished, AIPF, 2008.

FUNDING, PASSION, VISION, & LEADERSHIP EXPANDING NETWORKS, EVIDENCE, & EDUCATION

The key policy shift for helmet usage was greatly enabled by a significant increase in the number of players involved in the helmet use movement. The international, national, and local synergy electrified the participants. The interaction among the three levels contributed to the development of an empowered and impassioned local movement that accomplished its mission on Helmet Day. If there was a tsunami of legislation during this time period, it was equaled by the level of programming that occurred. While not always well coordinated, planning and organization increased significantly. Individually and collectively, the many players accomplished a great deal and helped the Vietnamese Government and the Party push on to Helmet Day. One of the most important leaders to join the effort in this period was the Prime Minister, who lent his personal prestige and moral suasion to the movement and by his personal involvement set a positive example for government officials.

Significant donors joined Atlantic in funding the work in Vietnam after the UN adopted the 2005 General Assembly Resolution on Improving Global Road Safety, which prescribed helmet use, among other important measures. The network of organizations that supported the UN resolution began to look at Vietnam as an initial site for its application and saw AIPF as an able facilitator. This led to the World Bank’s Global Road Safety Facility (GRS Facility) and the Bloomberg Family Foundation becoming two key new donors.

The GRS Facility would use Vietnam to spearhead a fifteen-year road safety project, intended to become a model project for the world. The first phase – budgeted at $31.7 million – was approved in 2005, with a small helmet-related piece involving road user education. This was in addition to work that the World Bank was already doing through the Global Road Safety Initiative (GRSI). Since 2002, the GRSI had been running programs in Vietnam through its international coordinator, the Global Road Safety Partnership, which partnered with AIPF. It would later select Vietnam as one of the country beneficiaries of its $10 million funding from Ford Motors, General Motors, Michelin, Renault, Shell, and Toyota.

The Bloomberg Family Foundation gave WHO $9 million to support its new Global Road Safety Program mandate, the result of a 2004 WHO resolution on road safety and health. WHO allocated $860,000 to Vietnam to work with the Ministry of Health on helmet use.

There was much collaboration and cooperation among funders and advocates on communications and education work. SIDA continued to fund the Ministry of Health to carry out the Swedish-Vietnam Safe Community collaboration through 2007, and affiliate Safe Community Network Members all participated in helmet use training and education. At the beginning of 2006, the program produced national guidelines on criteria for awarding safe family, safe community, and safe school certificates that included helmet wearing.

As in previous periods, AIPF was a linchpin. The organization provided free helmets and a safety demonstration to one of the Safe Community schools and was also a member of a Make Roads Safe campaign coordinated by the FIA Foundation. That coalition had lobbied hard for the government resolutions and – guided by AIPF – brought spokesperson Michelle Yeoh to Vietnam to promote helmet use.

The Center for Injury Prevention and Policy Research (CIPPR) at the Ha Noi School of Public Health inspired the movement by helping to provide answers and evidence related to the issues. CIPPR mobilized the HSPH and the Viet Nam Public Health Association to support early wearing of helmets (from September 15th).

There also continued to be no shortage of individuals with passion, vision, and leadership abilities. New advocates joined with old hands, none of whom dropped off the track as the work continued. Greig Craft of AIPF, in particular, brought a huge passion for the helmet use issue to his work. His belief that a private-public partnership could result in a viable non-profit helmet factory kept AIPF going through extremely trying times for the factory.

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ACTION COALESCES AT KEY MOMENTS AIPF and the rest of the nascent network joined forces at two pivotal moments during this period. The first key moment was the National Helmet Action Plan Workshop in December 2006. Co-chaired by the Global Road Safety Partnership and the French Red Cross, the workshop was organized by AIPF and the NTSC. The 2006 WHO publication Helmets: A Road Safety Manual for Decision-makers and Practitioners, available in Vietnamese, provided a framework for planning Helmet Day. Mr. Long, Secretary of the NTSC, was convinced enough of the soundness of the resulting National Helmet Action Plan and the backing of the international players that he proposed December 2008 to the Government as the start of mandatory helmet wearing. We believe the action plan inspired the Government’s adoption of helmet wearing nationwide within Resolution No. 32 and directly influenced the Prime Minister’s approval.

The second key moment was the national helmet wearing campaign held in March and April 2007. Greig Craft, AIPF President, chose to try a new approach to public education and worked closely with Ogilvy & Mather (Vietnam) on an extraordinary campaign called “Enough is Enough” and “No Excuses . . . Wear a Helmet.” Launched during the first UN Road Safety Week, the campaign was made possible by funding from the National Helmet Wearing Coalition, which was made up of international groups, embassies, and others that Mr. Craft had asked Klaus Rohland at the World Bank to pull together to raise money. The campaign would go on to win an award for communications work. The NTSC credits AIPF’s education campaign for influencing the Government to move up the date for mandatory helmet use to December 15, 2007.

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The immediate success of Helmet Day caused a stir that lasted through the month and well into 2008. All the involved parties had worked extraordinarily well together. There was inspiration all around, and the Prime Minister had shown encompassing, true leadership.

The 98% to 100% compliance rate in both cities and the countryside shocked everyone. Da Nang’s helmet use went from about 4% to 98% overnight.4 Ha Noi and Ho Chi Minh City were closer to 99%.5 Many groups that had worked to make this happen expected from 50% to 80% compliance. Atlantic’s Country Manager, Le Nhan Phuong, had hoped for 70% but would have been happy with 50%. AIPF anticipated 70%. CIPPR hoped for 60% to 70%.

The entire exercise in behavior change was an enormous accomplishment, a victory over the many obstacles to mandatory helmet use. There is no way to count the amount of time, energy, and physical and financial resources that went into the lead up to Helmet Day. It is clear that it all cost more than might have ever been imagined by the primary players. That it surprised them all in its success says a great deal. The results of the day itself and the days after deserved the attention they received. The Government, people, and partners of Vietnam achieved results that most developing countries could only dream about. That helmet use would need to be fine-tuned was certain, but that was also normal and anticipated. The overall achievement of the day was not normal at all. It remained wondrous for some time before the fine-tuning had to begin in earnest.

4 Ian Scott, The Alliance for Safe Children, June 2008 interview. 5 Bui Huynh Long, National Traffic Safety Committee, August 2008 interview.

AN INITIAL ENDPOINT DEC 15. 2007

What was different about Vietnam’s second attempt at universal helmet use? What was it in the final push that made Helmet Day possible? For over ten years, multiple actors contributed in a variety of ways. Certain conditions were created, some of which were necessary but not sufficient. Change happened only when the necessary and the sufficient coalesced.

All the organizations that we talked to agreed on most of the reasons for the success of universal mandatory helmet wearing this time around. Grounded in an overall increased intensity and momentum, they include:

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An enhanced legal, administrative, and social environment AND a rule for changing behavior that was:

• Based on sound data supporting the need for urgent action.• Issued by the highest political authorities: the Government,

the Party, and the National Assembly.• Communicated as an effective, urgent solution. It was

cleverly packaged within Resolution No. 32, which was not just about helmet wearing but described “urgent solutions” to traffic crises, traffic jams, and congestion.

• Clear to understand, communicate, and enforce verbally, visually, and in writing: ALL motorcycle riders and drivers on ALL roads.

• Universal.• Backed by a mix of coercive and social sanctions, deterrence,

and incentives. The fines cost more than a helmet. Being stopped for not wearing a helmet exposes a rider to being checked for other violations. The inconvenience of the paperwork and the time off required to pay fines at the Treasury office are also reasons to comply.

• Modeled by leaders and persons of authority. The Minister of Transport ordered his entire sector to comply before the deadline. He abandoned his car and rode his motorbike to work, wearing his helmet, on December 15th. Party leaders and civil servants signed “commitments” to abide by the helmet rule and other traffic safety rules.

• Enforced by all, with a determination to catch any violator. The enforcement machine was out in force. Police and Youth Union volunteers were on about every street corner in the cities. The numbers and types of police with authority to stop violators and levy fines increased exponentially. For example, 95,000 commune police workers joined the enforcement. Government workers were brought into the loop with tasks and deadlines. Deans and principals were responsible for “managing” students, ensuring their compliance, and “disciplining” violators. The Ministry of Health, the Ministry of Transport, and many other ministries and provincial authorities directed workers to sign commitments to wear helmets, with violators to receive no end-of-the-year performance recognition or awards.

• Strategically timed and phased in. September was designated official Safety Month, with helmet wearing compulsory on all national highways beginning on September 15th. The national highways are managed by the central government,

WHAT WAS DIFFERENT THIS TIME?

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which has more human resources and money than other administrators, allowing for tough enforcement that signaled the central level’s will, intent, and power to the local authorities and the general population. Success in September gave the Government and helmet use advocates momentum to proceed with the national campaign. December was chosen for the launch of universal helmet use on all roads based on findings that helmet compliance was higher during winter.

• Publicized and disseminated by mass media and every other means, with the aim of reaching every person at every level of society, from the cities to the mountains. Every step of the way, every piece of law and directive was made known to the public.

The means to comply through:

• The availability of appropriate helmets. Many manufacturers engaged in producing helmets, and helmets were generally well distributed and available throughout the country. There seemed to be enough different styles that people could find what they wanted. The Protec factory showed it was possible to make tropical helmets that are not hot, heavy, or ugly and gave their design plans to other companies to expand helmet supplies and availability.

• Verifiable quality and prices. The Government checked helmet quality and price and posted lists of those helmet producers who passed inspection and those who did not. State-owned enterprises were ordered to keep prices low.

• Subsidies and employee benefits. Thousands of civil servants as well as private sector workers received helmets or money to purchase them from their employer or organization. Corporations and factories distributed free or subsidized helmets to their staff, often with logos and designs. Protec made customized helmets for organizations, including the Ha Noi School of Public Health. Companies made Helmet Day a festival.

• Free helmet programs. The Government distributed 50,000 free helmets to the very poorest. Other organizations provided free helmets as well. As of June 2008, Helmets for Kids had distributed 350,000.

• Opportunities for innovation and resourcefulness. The insurance industry marketed personal injury and liability insurance along with a helmet – for the same price, a 2-in-1

“Insurance Helmet.” People started decorating their helmets, and young people began investing in several “fashion” helmets. People quickly solved the problems of where to store helmets and how to protect them from thievery.

Strong education and awareness efforts, with a clear message that was:

• Communicated by creative and prolonged campaigns. There was an early, creative, and hard-hitting education campaign from AIPF and the NTSC. The messages were clear and tough because they were about real people with head injuries. It was planned carefully over more than a year’s time. It used new ways of getting messages across. It worked well enough that the Prime Minister was deeply moved by the TV ads and pushed up the date for compliance by an entire year, from December 2008 to December 2007. The Government had monthly campaigns and then went all out the week before Helmet Day.

• Funded by donors and the Government. AIPF was able to mobilize the Danish, Australian, and U.S. embassies, Intel, Michelin, the World Bank, the Asian Development Bank, and WHO to support the helmet use communications campaign.

• Intended to reach everyone. Through the reach of mass organizations, everyone knew what December 15th meant. They also knew the consequences of not wearing a helmet: physical, legal, social, and financial.

Effective planning and coordination, from the top to the grassroots:

• Everyone involved pulled together, including the Party, the Government, mass organizations at all levels, the HSPH, schools, researchers, the UN and bilateral agencies, and international and local NGOs.

• The Prime Minister directed the campaign to its success and beyond.

• The NTSC provided very careful planning, including a detailed set of tasks for each ministry and their departments, with deadlines and a report-back scheme. No one was allowed to drop the ball, and everyone was supported.

• Mass organizations mobilized zealously from the grassroots up. Everywhere, Helmet Day used excitement to get people to put their helmets on. It was a fun day of collective action.

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SUSTAINING AND FINE-TUNING SUCCESS

A new cultural characteristic was established.

Saigon Giai Phong newspaperDecember 16, 2007

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Two years later, the sudden and dramatic behavior change seen on December 15, 2007, has become the norm. According to a Ministry of Health/WHO road observation study in Yen Bai, Da Nang, and Binh Duong, helmet usage has not significantly diminished as one might expect. The figures for drivers wearing helmets were 91.7%, 86.3%, and 98.5%, respectively, by the end of May 2009. The percentages of passengers wearing helmets were somewhat lower at 81.1%, 86.3%, and 91.6%, but overall the observed usage changes were positive.6 These rates are representative of other provinces, some of which have even higher compliance. By November 2009, the helmet use rate for adults was still around 90%.7

After the success of Helmet Day, the coalition of domestic and international players remained committed and was able to forge ahead to sustain the behavior change already in place, expand helmet usage, and enhance health outcomes. With usage remaining up, the coalition was able to focus attention on some of what had been considered second-order issues – helmets for children, helmet quality, properly worn helmets, and monitoring. Real progress has now been made in several critical areas.

HELMETS FOR CHILDRENWhile almost all children wore helmets on December 15th, within ten days, children’s helmet use fell to no more than 20% after a media report cited the opinion of a medical practitioner that helmet use might increase the risk of neck injuries. Unfortunately, even without evidence, parents believed these reports, and almost overnight helmets disappeared from most children’s heads. We now know the medical professional was likely misquoted, misunderstood, and misreported, but the erroneous negative opinion spread throughout Vietnam.

Parents and young teenagers also quickly found out that there were no fines for children under age 16, and fines for drivers and riders aged 16–18 were only half the adult fine. From age 16 up to their 18th birthday, minors can operate a moped of less than 50cc, with no license required. The sanctions in place for this large group of teenagers have not been strong enough to get them to wear helmets, even though operators of this class of vehicle are still bound by all requirements of the Law on Road Traffic. Financial penalties for not wearing helmets are frequently not administered to this group. Instead police inform the school at which the youth is registered, and the type of punishment (frequently some form of academic punishment) is deferred to the school.

6 Vietnam Ministry of Health and WHO, Report: Helmet Observation in Yen Bai, Da Nang and Binh Duong, May 2009 (Ha Noi: 2009).7 Jon Passmore and Nguyen Phuong Nam, WHO, October 2009 interview.8 Vietnam Ministry of Health and WHO, “Effect of Mandatory Motorcycle Wearing on Head Injuries in Vietnam,” unpublished, August 2008.

ENHANCING HEALTH OUTCOMES The Ministry of Health – with WHO’s technical assistance – carried out monitoring at 20 provincial and central hospitals over three months before and after Helmet Day. Results showed a decrease of 24% in patients admitted with head injuries and 14% in road traffic deaths.8 Other Government monitoring reports from the first six months of mandatory helmet use supported these findings.

While universal mandatory helmet use was clearly having a positive effect on health outcomes, many more people would have been saved if they had used helmets correctly. Thus, continued work is indicated in three key areas:

HELMET AVAILABILITYSafe, affordable helmets have to be accessible in all sizes for persons of all ages and incomes.

• Helmets for children and infants need to be more widely available.

• A way to provide helmets to the poorest segment of the population has to be found, including possibly requiring helmet manufacturers to give a percentage of their production to a fund for the poor.

HELMET STANDARDS & QUALITYLarge numbers of helmets do not meet the Government’s helmet standards, providing users with false security.

• Helmet quality mandated through the National Standards for Helmets must be applied to all helmets in Vietnam and fully enforced.

• The market needs to be better monitored. The helmet trade needs to be better understood and controlled. This relates to importation and smuggling as well as local manufacturers. Problems keeping up with demand for new quality helmets may arise or there could be market over-saturation – it will be hard to predict which and when. Coordination on quality involves three ministries, and no one seems able to control the helmet sources or the retailers.

• Side effects of helmets, health problems or skin diseases – especially with regard to substandard helmets – need to be explored. Some inferior helmets have contributed to facial injuries. Others can make the wearer’s head very hot and sweaty, are unwashable and quickly become smelly, and/or have faulty clasps.

• Standards for helmets used on high-speed highways need to be reassessed.

• An enhanced regime of product liability and consumer protection needs to be developed.

SAFE & EFFECTIVE USEDespite all the education around Helmet Day, many people wear helmets in incorrect and dangerous ways. On January 3, 2008, Vietnam News online reported a survey finding 88% of users wearing helmets incorrectly: (1) not buckling the strap, (2) putting the helmet on badly, (3) wearing a too-loose strap, or (4) wearing the helmet over or under other hats.

• Failure to wear helmets correctly must be penalized if helmet use is to be optimally effective.

• Parents need enhanced training in how to fit children’s helmets.

• Medical professionals need education in proper helmet use to avoid misinforming their patients and the public at large.

• Warning labels and instructions for use should be required to be provided with every helmet.

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Getting children to wear helmets became the focus for concerted action over the next two years. It took time to realize that the story of possible neck injuries could not just be talked away, that parents’ deeply fundamental belief in it would not just disappear. In response, the coalition decided to accelerate work in two areas: (1) with the Government to remedy the fines loophole in the law that essentially allowed children to go without helmets, and (2) in public education targeted to parents.

As a result, the Government approved a new schedule of fines in Decree No. 34, issued on April 2, 2010. Effective May 20, 2010, the new decree fines the driver when any passenger aged 6 or older is not wearing a helmet or does not have the helmet strap fastened. Thus, adult drivers are now held accountable for the helmet use compliance of their child passengers. The decree will also make it easier for authorities to enforce child helmet usage through schools and parent associations, and police can reach these groups for training. Schools can be marked down on performance ratings if their students do not comply. In turn, schools can require parents to assure child helmet use. The decree is not perfect, but it is a place from which to build in the future.

Fines for passengers under 6 are still not covered by the decree. While WHO understands that all children should wear helmets and has pressed the Government on this, they also believe they have pushed as much as they can just now to get new sanctions for children’s helmet use approved. They recognized that helmets for children 6 and older was the best that could be achieved in 2010, given that many parents and leaders still remain apprehensive about helmets on younger children.

Public education targeted to parents has included public service announcements made by AIPF to correct the medical evidence. In the attempt to move to helmet wearing for safety’s sake (not just to avoid fines), a required school-based driver’s education program for youth between 16 and 18 years old could be the venue for safe driving training related to helmets and other issues. In this context, films can be of great use. This could be expanded beyond the school context for first-time licensees who are not in school.

HELMET QUALITYIn November 2008, the existing adult and child helmet standards were revised into a single consolidated, government-approved National Standards for Helmets. Enforcement is, however, very weak, with too many helmets of extremely poor quality in shops and on heads. Some measures to be taken include cracking down on illegal and substandard helmets at the manufacturing

and distribution points and having police become more active in fining people for using them.

Protec has developed suitable and safe helmets for children – including those under 6 – and to further encourage their use, has expanded the styles available. Protec reports that its smallest helmets fit some children as young as 6 months old, depending on the head form. Helmets for children 5 and older are also available through other companies, including Honda and Zeus. Still, according to AIPF, Protec is the only legitimate producer in Vietnam of the smallest helmets, and that is not expected to change with the new decree, as the continued lack of a market for children under 6 will not encourage other producers.

PROPERLY WORN HELMETSSome helmet wearing is clearly to avoid fines and not for safety. By the end of August 2008, there were many people with helmets with unbuckled straps riding around on the streets of Ha Noi.

In response, in November 2008 the Ministry of Public Security put out a circular equating unfastened helmets to no helmet at all and stipulating hefty fines for drivers and passengers who don’t use their helmet straps. Application of this new regulation can be credited with a noticeable increase in the number of properly fastened helmets.

MONITORINGIn October 2007, to help evaluate the effects of helmet use over time on morbidity and mortality resulting from accident-related injuries, the General Department of Preventive Medicine and Environmental Health, of the Ministry of Health, developed a monitoring project to focus on traffic injuries – particularly head injuries, helmet use, and helmet quality – beginning with 20 hospitals. This was later expanded to cover 100 hospitals in 63 provinces and cities.

Monitoring occurs in the emergency departments of most of these hospitals. WHO helped roll out and supports this project, including doing training in the hospitals. There are unresolved problems with the project: lack of dedicated staff, bias from self-reporting by accident victims or families, and a lack of linkage between this monitoring and that done by the police. Accurate data collection is further complicated by the fact that an admission of not wearing a helmet can result in an insurance company refusing to pay for hospitalization.

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While the strong and united coalition has accomplished a great deal in the two years since Helmet Day, there are still too many people wearing helmets incorrectly and some not wearing them at all. In Ha Noi fewer drivers (especially the young and hip) wear helmets on the weekends, at night, and on back streets because there are not as many police around to enforce the law. Too many people buy poor-quality helmets still found in the markets despite strengthened helmet standards. The smallest children are still not required to wear helmets. Helmetless bicyclists remain at the mercy of fast-paced cars and motorbikes. Enforcement can be spotty on less-traveled roads outside the cities. Most problematic for long-term behavior change, the safety benefits of helmets are still not fully understood.

There is much yet to be done to further enhance health outcomes and expand helmet usage through the four key building blocks that enabled change to be sustained and enhanced over the past two years:

• Development of data to add to the evidence base for mandatory universal helmet use, including a way to quickly address false rumors about the dangers of using helmets.

• Education and awareness programming, including work to enhance media knowledge and improve reporting.

• Legal capacity building to ensure that subsequent policy change is institutionalized in a clear, comprehensive set of rules, fines, and enforcement measures.

• Monitoring through a better national program to document the benefits of helmet wearing and also provide feedback for legislative refinement, public education, and legal enforcement. This includes helmet monitoring in the countryside to measure enforcement, levels of poverty, and guaranteed access to helmets.

What is most important is that Vietnam now has a strong model for collective mobilization of government and society for injury and illness prevention. This can be replicated as the authorities and their national and international partners search for ways to internalize these four tasks so that they become a normal part of the continuous effort to fine-tune the system. The more time that passes, the harder it will be to maintain momentum and maximum effort. Thus, tasks such as these must become accepted as standard to the way government and society interact.

STEPPING UP THE PRESSURE

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THE PRIMARY LESSON OF THE HELMET DAY STORY IS THAT POLICY CHANGE CAN BE AN IMPORTANT ELEMENT IN BEHAVIORAL CHANGE, ESPECIALLY IN AN ENVIRONMENT, SUCH AS VIETNAM, WHERE THE GOVERNMENT IS A MAJOR PLAYER. It is more complex though than simply making a law and providing for its implementation. The Government set the policy target, became thoroughly committed to the cause, acquired the knowledge about implementation strategies, and mobilized all the other parts of the State to achieve the goal. At the same time, there were additional people involved who – driven by a passion for the work – brought money, knowledge, and leverage to the mix. They knew how to make things happen, were risk-takers when they needed to be, and had the experience to step back and imagine the results. These people were, in this context, a mixture of Vietnamese and international actors whose skills and knowledge were complementary. Planning and coordination among these players was critical so that essential factors could come powerfully together. Without that eventual synchronization, failure was likely.

THE SECOND CRITICAL LESSON DRAWN FROM OUR EXPERIENCE IN VIETNAM IS THAT INITIAL CHANGE MUST BE SUSTAINED AND SUPPLEMENTED. The initial change will always be imperfect. There will always be the need to sustain and fine-tune policies and behaviors after the initial change takes hold. It is important to plan for this from the outset and not attempt more than is doable. The initial focus of attention in Vietnam was on getting appropriate helmets on most heads. This was seen as the first step, with secondary attention to issues such as helmet quality, proper use, and sustainability of the effort. We believe that, whether handled in phases or thought through all at once, a behavior change strategy that aims for mass adoption must be coupled with a strategy and action plan for sustaining change and enhancing health outcomes in the longer term. In our case study of changing behavior around helmet use in Vietnam, we see the gradual evolution of a well-thought-out plan for getting everyone to wear helmets. We do not see a similar plan for sustaining the change and addressing anticipated and unanticipated second-order challenges. Developments after the initial success of Helmet Day revealed some remaining barriers and emerging challenges that had to be addressed – in particular, getting helmets back on the heads of children.

There was a coalescing behind the notion of helmet law and helmet use. The involvement of many players had finally grown into a movement that had more clout, and the Vietnamese players were more of a collective force than ever before.

Le Nhan Phuong The Atlantic Philanthropies

LESSONS LEARNED: POTENTIAL APPLICATIONS TO OTHER PUBLIC HEALTH BEHAVIOR CHANGE PROGRAMS

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PRIMARY LESSONS

In the lead up to Helmet Day, the strong Government desire to legislate on this matter and their ability to develop and implement a logical legal frame had finally come together. At the same time, sufficient resources were available – including passionate and knowledgeable leaders and funders, both Vietnamese and international – to provide the underpinnings that would enable behavior change. In a departure from the dualism that can too often undermine effective collaboration, international participants played positive roles both externally, bringing pressure and funding to bear around the problem, and internally, engaging fully on the ground to create and support coalitions that could drive achievable solutions.

There are many lessons from Vietnam’s helmet story that can be applied to other public health issues that involve programming to change embedded socio-cultural norms and individual behavior. Below we present our preliminary thoughts. We look forward to further brainstorming on what we have learned and what might be useful in developing behavior change programming for other injury prevention and public health areas in Vietnam and elsewhere.

• THERE NEEDS TO BE A CREDIBLE, UNDERSTANDABLE KNOWLEDGE BASE. Evidence provides a foundation for government and advocate commitment and stimulates public awareness and engagement.

• CULTURAL CONTEXT IS CRITICAL. Changing norms of behavior and sustaining the change requires an understanding of socio-cultural enablers and barriers. Social conformity is strong in Vietnam and blocked any significant “early adopters” for voluntary change. Vietnamese often do not want to stick out from the crowd. This makes it hard to be the first ones to do something differently. In the case of helmet use, many people did not want to be the only ones wearing them, even if they knew they should do so. Having everyone do it at once was a facilitator.

• A COMPULSORY ELEMENT IS OFTEN ESSENTIAL TO CHANGING RISKY BEHAVIORS. It takes money and time to develop and fine-tune effective rules to limit injury and illness. This includes compulsory use of life jackets, seat belts, and child seats; standards for buildings; safety codes to prevent burns and poisoning; and smoking bans in certain indoor environments. It is important to be creative in thinking through scenarios and testing new policies and regulations on the public. Therefore, public health safety programs can take a decade or more to build, and funders and other stakeholders need to be prepared to engage long term.

• ANY REGULATION MUST BE CLEAR AND EASY TO UNDERSTAND – AND WELL COMMUNICATED. Regulation needs to be communicated unambiguously in policy and legal documents, taught in schools and other community forums, dramatized in songs and plays and other public performances, disseminated accurately by mass media, or conveyed through everyday conversation. Regardless of its means of delivery, the message about the desired action and the consequences for not complying (social, health, financial, and legal) must be clear to those who are expected to act. These consequences must also be clear to those who are to enforce or reinforce that action through police work, social sanction, or other penalties or incentives.

• ALL ESSENTIAL PIECES OF LEGISLATION MUST BE IN PLACE AT THE SAME TIME – the legal authority, the rule, and the sanction, as well as the instructions for implementation and enforcement.

• EDUCATION AND COMMUNICATIONS MUST BE APPROPRIATE TO THE AUDIENCE AND CULTURAL CONTEXT, CREATIVE, CLEAR, REPEATED, TRUTHFUL, AND LINKED TO EVIDENCE. For example, behavior change messages focusing on children can help reach adults. Active teaching methodology can be effectively used, but the message needs to stand out. Programs need to be piloted and tested to avoid unexpected results that then have to be retracted. While essential, community awareness programs are sometimes hard to fund and government approval can take a long time.

• EDUCATION AND COMMUNICATIONS EFFORTS MUST BE SIMULTANEOUS AND CONSTANT.

• CAPACITY-BUILDING AMONG KEY PLAYERS IS ESSENTIAL. Knowledge is increased through cross-fertilization, brainstorming, collaboration, and the sharing of ideas. Effectiveness can be exponentially expanded through mutual support of efforts.

• LOCAL-INTERNATIONAL PARTNERSHIPS BOTH DEVELOP NEW AND ADAPT OLDER BEST PRACTICES. Such partnerships also put pressure on authorities to keep up momentum as well as attracting funders to the issue. This can help expedite project implementation.

• GLOBAL-LOCAL INTERACTION CAN AMPLIFY MESSAGING. Global emphasis on an issue can assist governments in achieving their goals. In Vietnam, UN interest in and support of the helmet use issue was used by the Government to call attention to the project and move it forward. Reciprocally, the program’s successful implementation brought praise for the leadership and effectiveness of both the Government and the global community, enhancing their legitimacy.

• PRIVATE-PUBLIC PARTNERSHIPS CAN BE BUILT TO FUND AND IMPLEMENT INJURY PREVENTION AND OTHER PUBLIC HEALTH PROGRAMS. These partnerships were embraced by the Vietnamese Government, which actively promotes “socialization,” or the participation of all in producing public goods. AIPF itself was a private-public model and funded the Protec factory that way. It also successfully drew corporations into supporting traffic safety education and the Helmets for Kids program.

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ADDITIONAL LESSONS

Additional lessons learned that could be potentially applied to other public health behavior change programs include the following:

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PRE -1997LOCAL ACTORSMinistry of Health

Ministry of Transport

Ministry of Home Affairs (now the Ministry of Public Security)

Government Committee on Organization and Personnel (now the Ministry of Home Affairs)

Traffic Safety Steering Committee (replaced by the National Traffic Safety Committee in 1997)

Health Policy and Strategy Institute

The People’s Committee of Ho Chi Minh City

Nguyen Van Thuong, Deputy Minister, Ministry of Health

Bui Huynh Long, Ministry of Transport

INTERNATIONAL ACTORSSwedish International Development Authority (now the Swedish International Development Cooperation Agency)

WHO/FIA Foundation Helmet Initiative

Leif Svanström, Lund University, WHO Collaborating Centre on Community Safety Promotions, Karolinska Institutet

APPENDIX: THE ACTORS IN VIETNAM’S HELMET STORY

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JOINED 1997-2001

JOINED 2002-2007

LOCAL ACTORSNational Assembly

Ministry of National Defense

Ministry of Finance

Ministry of Justice

Ministry of Education and Training

Ministry of Science and Technology

General Department of Preventive Medicine and HIV/AIDS (from 2005 to 2007 the Vietnam Administration of Preventive Medicine; from 2007 to 2009 the General Department of Preventive Medicine and Environmental Health; and now the Department of Preventive Medicine), Ministry of Health*National Traffic Safety Committee

National Steering Committee on Injury Prevention and Control

Viet Nam Committee for Population, Family and Children

Provincial and municipal Traffic Safety Committees

Police

Ha Noi School of Public Health*

Viet Nam Red Cross

Viet Nam Fatherland Front, Viet Nam Farmers Union, Viet Nam Women’s Union, and other mass organizations

Nguyen Tan Dung, Deputy Prime Minister (September 1997–May 2006), Prime Minister (June 2006–current)

Nguyen Trong An (currently Deputy Director, Department for Children Care and Protection, Ministry of Labour, War Invalids and Social Affairs)

INTERNATIONAL ACTORSAustralian Embassy

U.S. Embassy

U.S. Centers for Disease Control and Prevention

USAID

U.S. Fund for UNICEF*UNICEF*The Atlantic Philanthropies

The Safe Viet Nam Initiative

Harborview Injury Prevention and Research Center, University of Washington*Pete Peterson, U.S. Ambassador

Mike Linnan, Centers for Disease Control and Prevention, Health Attaché, U.S. Embassy

Michael Mann, Australian Ambassador

Chuck Feeney, The Atlantic Philanthropies

Chris Oechsli, The Atlantic Philanthropies

Morten Giersing, Country Representative, UNICEF Vietnam

Huan Linnan, The Safe Viet Nam Initiative, UNICEF

Greig Craft, founder of Asia Injury Prevention Foundation

Le Nhan Phuong, Ha Noi School of Public Health, The Atlantic Philanthropies

Charles Mock, Harborview Injury Prevention and Research Center

U.S. President Bill Clinton

LOCAL ACTORSThe Communist Party of Vietnam, Politburo, and Secretariat

All other ministries and agencies at every administrative level

Yen Bai, Vinh Phuc, Tuyen Quang, Nghe An, Bac Ninh, Binh Duong, and Da Nang Provinces

Center for Injury Policy and Prevention Research, Ha Noi School of Public Health*Viet Nam Public Health Association*Injury Prevention Network

Mass media (VTV, newspaper, radio)

Ho Nghia Dung, Minister of Transport

Pham Viet Cuong, Center for Injury Policy and Prevention Research, Ha Noi School of Public Health

Miss Viet Nam 2006 and other local celebrities

Motorcycle drivers and riders

INTERNATIONAL ACTORSWorld Bank

Global Road Safety Facility

Global Road Safety Initiative

Global Road Safety Partnership

Bloomberg Family Foundation

UN General Assembly

UN Development Programme

WHO Vietnam*Child Injury Prevention Unit, UNICEF Vietnam*Center for Accident and Road Safety, University of Queensland*French Red Cross

The Alliance for Safe Children*

Asia Injury Prevention Foundation*Vietnam Safety Products and Equipment Co. (AIPF Protec helmet factory)*The Government of the Netherlands

Asian Development Bank and ASEAN Regional Road Safety Program

APEC Transportation Committee

Japan Automobile Manufacturers Association and Japan Auto Parts Industries Association

Ogilvy & Mather (Vietnam)

National Helmet Wearing Coalition

The Royal Danish Embassy

Danish International Development Agency

Counterpart International*Toyota Vietnam Foundation

Klaus Rohland, World Bank

Ian Scott, The Alliance for Safe Children

Jon Passmore, WHO Vietnam

Isabelle Bardem, UNICEF-Vietnam

Jackie Chan

Michelle Yeoh

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* The Atlantic Philanthropies grantee

The Social Science Research CouncilOne Pierrepont PlazaBrooklyn, NY 11201www.ssrc.org